Innovative Use of Sclerotherapy for Management of Refractory Thoracic Costovertebral Instability and Pain: A Case Report

Case Diagnosis: A 28-year-old woman with painful refractory thoracic costovertebral joint instability

Case Description or Program Description: The patient is a 28-year-old woman with a 4-year history of left-sided rib pain. She has a past medical history significant for bilateral lower extremity compartment syndrome requiring multicompartment fasciotomies, which were complicated by multi-tendon dysfunction and subsequent surgical intervention. For her left rib pain, she has undergone extensive medical and procedural management, including costovertebral and facet joint injections, intercostal nerve blocks, epidural steroid injections, trigger point injections, and left 9th & 10th anterior cartilage and partial rib resections. She presents to clinic with continued, severe rib pain for which she received sclerotherapy with an injection of dextrose and lidocaine targeting the left T9 and T10 costovertebral joints, as well as the anterior regions between T8-9 and T9-10. She was instructed to wear a rib-belt for 10 days with subsequent return to normal activity and follow-up in clinic.

Setting: Outpatient Musculoskeletal Medicine Clinic

Assessment/Results: In clinic, the patient experienced immediate, >50% post-procedural pain relief from 7/10 severity to 3/10 in pain severity. She did not experience any painful joint subluxation with her typical provocative maneuvers post-procedurally.

Discussion (relevance): Management of intractable pain due to costovertebral joint instability can be challenging. Soft-tissue sclerotherapy has been proven to be beneficial for treating other areas of joint instability, such as soft-tissue sclerotherapy of the knee, elbow, and shoulder. However, this is the first documented case describing the utility of sclerotherapy for costovertebral joint instability.

Conclusions: Sclerotherapy may be a beneficial option for treatment of pain and instability in cases of refractory thoracic costovertebral joint instability.